SMS QAPI slides WHCA 5-2017 - WiHCA/WiCAL · Neither SMS nor its employees shall be liable to you or any other person or entity for any loss or injury or any direct, indirect, incidental,

QAPI Overview5‐24‐2017

5/18/2017

5343 North 118th Court Milwaukee WI 53225

414 476 1112 ext. [email protected]

QAPI: An OverviewPresented for WHCA 5-24-2017

5343 North 118th CourtMilwaukee WI 53225414 476 1112 fax 414 476 6118www.specializedmed.com

The materials contained herein include information and facts and the opinions and recommendations of

Specialized Medical Services, Inc. (SMS) regarding governmental regulations, statutes and practices, and potential changes to same. Notwithstanding

anything to the contrary stated or implied in any of the materials available herein, SMS and its employees cannot and do not make any representation, warranty, endorsement or guarantee, express or implied,

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arising out of any of the materials (or any portion thereof) contained or not contained herein. BY ATTENDING THIS SEMINAR, YOU HEREBY WAIVE ANY AND ALL CLAIMS AGAINST SMS AND

ITS EMPLOYEES ARISING OUT OF YOUR USE OF THE INFORMATION CONTAINED HEREIN.We have provided URL addresses to Internet sites maintained by third parties. Neither SMS nor its

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Specialized Medical Services, Inc.5343 North 118th Court

Milwaukee, WI 53225 414-476-1112 fax 414-476-6118

email: [email protected]

Presenter: Theresa Lang, RN, BSN, WCCVice President Clinical ConsultingSMS for 21 yearsOver 40 years LTC experienceAreas of Expertise

AHIMA Approved ICD-10 Trainer Clinical Operations and Training Medicare MDS Wound Care

[email protected]

WHAT IS QAPI?QAPI is a data‐driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to:

identify opportunities for improvement;address gaps in systems or processes; develop and implement an improvement or corrective plan; and

continuously monitor effectiveness of interventions.

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QAPI is a regulation• The Affordable Care Act of 2010 requires

nursing homes to have an acceptable QAPI plan within a year of the promulgation of a final rule QAPI regulation.

• The QAPI regulation was supposed to be published in November of 2012…The QAPI regulation was expected to be publishedin 2013. That did not occur

• QAPI regulation was published in November 2016

• Begins with facility assessment in Phase 2-November 2017• Implementation Plan

Two functions that go hand in hand

QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). Both involve using information, but differ in key ways:

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Quality Assurance

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• Quality assurance involves measuring and tracking indicators to find out where the facility is performing well, and where there are opportunities for improvement.

QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.

Performance Improvement

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• Performance improvement is the reaction and correction to an opportunity to improve.

PI (also called Quality Improvement ‐ QI)

is a pro‐active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.

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Create a “Just Culture”In a non-punitive culture the individual is held accountable for his or her actions. The organization acknowledges that human error is not only possible, it is likely under certain circumstances.

Staff are held to professional accountability in admitting errors, including their own errors, to improve systems and prevent further errors.

Create a “Just Culture”A non-punitive work environment is one in which it is recognized that many individual errors are predictable and unavoidable when human beings, including highly skilled human beings, interact with and use systems and equipment.

It acknowledges that individuals should not be held accountable for errors over which they have no control.

1. Design and Scope

4. Performance Improvement Projects (PIPs)

3. Feedback, Data Systems

and Monitoring

2. Governanceand Leadership

5. Systematic Analysis and

Systemic Action

The Five Elements of QAPI

Your QAPI process has to measureyour compliance in every department, and against every part of the regulation. And it’s not just a onetime look.DESIGN AND SCOPE

QAPI Element #1:

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1. Design and ScopeQAPIQAPI is Ongoing and Comprehensive within the facility.

Deals with all services offered and all departments.

Should include Clinical Care, Quality of Life, ResidentChoice, and Care Transitions.

Utilizes the best available evidence to define andmeasure goals.

Nursing homes will have in place a written QAPI plan.

Who is going to takingresponsibility and how?

GOVERNANCE ANDLEADERSHIP

QAPI Element #2

2. Governance and LeadershipQAPIAdministration leads QAPI with input from staff, residents,families.Provides training and equipment as needed for QAPI.

Establish policies to sustain the QAPI program despite changes inpersonnel and turnover

Set priorities for improvement.Ensures QAPI is adequately resourced with one or more personsaccountable.

Set expectations around safety, quality, rights, choice and respect.

Ensures that while staff are held accountable, there existsan atmosphere in which staff are not punished for errorsand do not fear retaliation for reporting quality concerns.

How are you getting data, and how willyou confirm, with measurement, thatwhat you are doing is working?

FEEDBACK, DATA SYSTEMS,AND MONITORING

QAPI Element #3

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3. Feedback, Data Systems, andMonitoring

QAPIFacility puts into place systems to monitor care andservices, drawing data from multiple sources.

Feedback systems actively incorporate input fromstaff, residents, families, and others as appropriate.

Performance Indicators monitor a wide range of careprocesses and outcomes.

Findings are reviewed against benchmarks and/or targets the facility has established for performance.

Includes tracking, investigating, and monitoring AdverseEvents.

Thresholds are a NON-ARBITRARY,

VALIDATEDbenchmark to help

you determine when an area needs a closer

look.

Prove that you are working on problems and that the success of yoursolutions is being measured.

PERFORMANCE IMPROVEMENTPROJECTS

QAPI Element #4 What are PIPs?• A Performance Improvement Project is

more than a casual effort - it entails aspecific written mission to look into aproblem area.

• During a PIP a facility will try out somechanges and then see whether or notthey made a difference in the area theywere trying to improve.

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A typical PIP identifies:• What the problem is• A PIP team that will work on it, meet, and

report back to the QAPI team in the building• Do root cause analysis to figure out what the

cause of the problem actually is (five whys, fishbone diagrams, etc. )

• What measure they will use to know if theywere successful

• What interventions they will do to fix the problem

Processes that can be used

PDSAPlan-Do- Study- Act

Plan- Do- Study- Act- Sustain

Root Cause Analysis

Root Cause Analysis

Root cause analysis (RCA) is a problem solving method or process for conducting an investigation into an incident, failure, actual or potential problem or concern. Events that can be investigated using the RCA process can be identified from many sources, such as incident reports, individual, family and staff feedback, surveys from regulatory agencies, an unexpected occurrence that led to individual or staff harm, or a repeating problem. RCA should also be considered for events that could have potential for a serious or negative outcome, such as “close call” or “near miss” incidents.

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Root Cause Analysis

1. Identify the event2. Select the team3. Describe the event4. Identify all the factors5. Identify root cause6. Change and measure7. Communicate and sustain

Which tool?

Which tool? Data Collection

Regardless of the tool that is chosen to use the first step is data collectionKeep the DC tool short and sweet

Only collect the necessary data

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Flowcharting

A flowchart is a pictorial representation describing a process being studied. Flow charts give team members a common reference point when analyzing a work process and planning for process improvement.

FlowchartingProcedure: Decide on the process to flowchart.

Define the beginning and ending steps of the process.

Use ovals to indicate the beginning and ending boundaries of a process.

Write the beginning step in an oval.

Use rectangles to indicate each successive action step in the process.

When a step in the process requires decision, write a yes/no question in a diamond and develop paths for either answer.

Write the ending step in an oval.

Process Mapping

In a process map, each “lane” is labeled with a care team member or location that is critical for the process to succeed.

Do not forget to include the resident.

Each step of the process is placed in the appropriate lane according to who is handling the step.

A process map allows the PIP team to see how many hand-offs occur during the process from start to finish. Unnecessary hand-offs signal inefficiencies and an increased opportunity for mistakes to occur.

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Process Mapping

Once you have completed theprocess map, ask the followingquestions:

Where are the bottlenecks? How can weaddress these?

Are there inconsistencies in howthings are done? What can bestandardized?

Process Mapping

Can things be done in a differentorder? In parallel? By a differentperson with better or the samequality, at a lower or the samecost?

Can steps be located closer together toreduce travel?

Does each step add value? If not, can itbe eliminated?

Flow Charting: Mapping symbols

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Flow Charting: Mapping symbolsFishbone Diagram: RCS

Root Cause Analysis allows the PIP Team to get at the “root” of the problem by better understanding where and why the problem exists.

Conducting a Root Cause Analysis guides the workgroup or Performance Improvement Committee to make decisions based on data rather than “hunches” and to seek lasting solutions rather than quick fixes.

Fishbone Diagram: RCS It is also known as the Cause and Effect

Diagram.

This tool is useful in assisting teams to focus on possible root causes of performance improvement issues.

The five main causes generally used are:Manpower/People

Environment

Material

Equipment

Methods/Processes

Fishbone: is working backward

Before creating the Fishbone Diagram, the desired outcome needs to be decided. Beginning with the desired outcome, work backward to identify the main factors that could affect that outcome and show them as the prominent branches or “bones” of the diagram’s structure.

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Fishbone: is working backward Procedure:

Identify the problem the group will work on. Write the problem in a box on the right side of a flip chart.

Draw the “fish” outline, a long horizontal line (backbone) coming from the box and a series of diagonal lines (rib bones) coming off of the backbone.

Identify the main branches with the categories of causes.

Fishbone: is working backward Procedure:

Brainstorm for specific causes, which contribute to the main branches.

Clarify as needed. Develop the causes by asking “why” until a useful level of detail is reached.

Under each main branch list all of the relevant factors associated with the branch that will influence the desired outcome.

RCA: The 5 Whys

Another method of completing a root cause analysis is by making a table that asks a series of questions.

The analysis repeatedly digs deeper by asking “Why?” then, when answered, “Why?” again, and so on until the cause of the issue is determined.

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Pareto Charts The Pareto Chart is a tool that helps teams see

which causes or problems occur most frequently. The chart plots out the activities or areas that contribute most to poor quality.

The Pareto Chart is based on the theory that a small number of causes will have the largest contribution to poor quality.

When a few activities contribute to most of the problem, it is called the Pareto Effect.

A classic Pareto Effect is observed when 20% of the causes contribute to 80% of the overall problem.

Pareto Charts Procedure:

Place the data captured in the Check Sheet into a table, in descending order. From this table, calculate the percentage frequency and the cumulative frequency.

Plot this information as a bar chart, where each vertical bar represents a different cause or problem and the left vertical axis represents the number of causes and problems.

Identify the bar where the cumulative frequency is high relative to the number of categories.

Look for a Pareto Effect, where the first few categories account for most of the problems.

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Trend or Run Charts

A trend chart gives visual representation of data over a period of time. It is also used to establish baseline performance, identify special cause variation and to compare members of a group with each other. Trend charts often include a line representing the average or mean of the data.

Trend/Run Chart Procedure Gather data in a chronological or sequential form.

Measurements must be taken over a period of time.

Divide the data into two sets of values, X and Y. The values for X represent the time intervals and the values for Y represent the measurements taken.

Plot the data for each time interval.

If an average or mean line is to be used, calculate and plot. Average or means is equal to the sum of all data points divided by the number of data points - i.e., 2, 5, 4, and 9 equals 20. Twenty divided by four equals an average of five.

Connect the points for easier visualization.

Bar Graph A bar graph is a chart that uses either

horizontal or vertical bars to show comparisons among categories. One axis of the chart shows the specific categories being compared, and the other axis represents a discrete value. Some bar graphs present bars clustered in groups of more than one (grouped bar graphs), and others show the bars divided into subparts to show cumulate effect (stacked bar graphs).

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Bar Graph Procedure Determine the discrete range. Examine your data to find

the bar with the largest value. This will help you determine the range of the vertical axis and the size of each increment. Then label the vertical axis.

Determine the number of bars. Examine your data to find how many bars your chart will contain. These may be single, grouped, or stacked bars. Use this number to draw and label the horizontal axis.

Determine the order of the bars. Bars may be arranged in any order. (A bar chart arranged from highest to lowest incidence is called a Pareto Chart.) Normally, bars showing frequency will be arranged in chronological (time) sequence. Draw the bars.

Pie Charts

Pie charts, a form of an area chart, are an easy way to visualize percentage breakdowns of a total. They’re useful for analyzing polls, statistics, and managing money and data. And they make an excellent visual display for explaining data to other people.

Pie Charts1. Calculate Pie Chart Proportions.

2. Gather your numerical data and label information and write it down with one data point per line, in descending order.

3. Add the data all together, calculate the total. This number will be your denominator.

4. Calculate the percentage of the total for each data point by dividing each one by the denominator (total) calculated above.

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Pie Charts Calculate the angle between the two sides

of each pie slice. To do this, multiply each percentage (still in decimal form) by 360 (the number of degrees in a circle).

Utilize the charting capabilities in Microsoft Office (Excel or Word). ORStart with a perfect circle

Divide into quadrants

Subdivide as needed

Group TechniquesTechnique When to use

Brainstorming

To generate many ideas in a short amount of time. Ideas are suggested while criticism and evaluation is avoided

Nominal Group Techniques

To generate a list of options for a structured decision through the contributions of group members working individually

Multi-Voting

To select the most important of popular topics from a list with limited group discussion and difficulty

Structured Discussion

To gain group consensus on a list of ideas or topics

High Volume, High Risk, Problem Prone, High Cost

To prioritize issues so that those issues with the largest impact are addressed first and resources are utilized appropriately

Prioritizing Issues

High volume, high risk, problem prone, and high cost is a technique used to prioritize issues so that issues with the largest impact are addressed first and resources are appropriately utilized.

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Prioritizing Priority of this topic:

Score each using the following1 Very Low

2 Low

3 Medium

4 High

5 Very High

Prioritizing _____ PREVALENCE : The frequency at which this

issue arises in our organization.

_____ RISK: The level to which this issue poses a risk to the well- being of our residents.

_____ COST: The cost incurred by our organization each time this issue occurs.

_____ RELEVANCE: The extent to which addressing this issue would affect resident quality of life and/or quality of care.

______ RESPONSIVENESS : The likelihood an initiative on this issue would address a need expressed by residents, family and/or staff.

______ CONTINUITY The level to which an initiative on this issue would support our organizational goals and priorities.

Prioritizing TOTAL PRIORITY SCORE: __________

1-5 Very Low priority

6-11 Low priority

12-17 Medium priority

18-23 High Priority

24-30 Very high priority

A LOW SCORE DOES NOT MEAN IT IS NOT A PRIORITY!

A low priority may have a great impact

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4. Performance Improvement Projects(PIPs)

QAPIThe facility conducts Performance Improvement Projects (PIPs) to examine andimprove care in areas that are identified asneeding attention.A PIP project is a concentrated effort on a particular problem.A PIP involves gathering information systematically to clarify issues orproblems, and intervening for improvements.

Your QAPI process isn’t just putting out fires, it’s fixing what’s wrong with the system.

SYSTEMATIC ANALYSIS ANDSYSTEMIC ACTION

QAPI Element #5

5. Systematic Analysis andSystemic Action

QAPI

The facility uses a systematic approach to determine whenin‐depth analysis is needed.

The facility uses an organized approach to determine ifidentified problems are caused by the way care is delivered.

Systemic Actions look comprehensively across all involved systems to prevent future events andpromote sustained improvement.

Facilities will be expected to develop policies andprocedures and demonstrate proficiency in the useof Root Cause Analysis.

Other Key Factor

Effective Meeting ManagementMeeting Rules

Meeting Roles

Documentation

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Resources

https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/qapitools.html

https://www.ahcancal.org/quality_improvement/qapi/pages/ default.aspx

MY FAVORITE: http://www.medline.com/media/mkt/pdf/ProvidigmQAPIToolkit.pdf

https://www.lsqin.org/initiatives/nursing‐home‐quality/

SMS Contact Information

Theresa Lang

Vice President Clinical Consulting

Specialized Medical Services, Inc.

414-476-1112 ext: 1217

800-786-3656

[email protected]

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Documents

SMS QAPI slides WHCA 5-2017 - WiHCA/WiCAL · Neither SMS nor its employees shall be liable to you or any other person or entity for any loss or injury or any direct, indirect, incidental,